pharmacist collaboration to learning objectives care...– 1 attending physician, 1-2 medical...
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Pharmacist Collaboration to Pharmacist Collaboration to Maximize Your PatientMaximize Your Patient--Centered Centered
Medical HomeMedical Home
Stuart Beatty, PharmD, BCACP, CDEAssociate Professor of Clinical Pharmacy
The Ohio State University College of Pharmacy
Learning ObjectivesLearning Objectives
• Describe how pharmacists can provide patient-centered, collaborative care in a primary care settingsetting
• Discuss a transitional care coordination workflow in a patient centered medical home
• Demonstrate effective population management initiatives
Pharmacist EducationPharmacist Education• Doctor of Pharmacy Degree
– 6-8 years education– 3 year emphasis:
• Medicinal chemistryPh l• Pharmacology
• Pharmacokinetics• Therapeutics
– 1 year experiential • Pharmacy Residency (elective)
– 1 or 2 years clinical experience
OSU General Internal MedicineOSU General Internal Medicine• Martha Morehouse GIM Clinic
• CarePoint East GIM Clinic
• Stoneridge GIM Clinic
• Grandview GIM Clinic
• Hilliard GIM Clinic
• Lewis Center Primary Care
• National Committee for Quality Assurance (NCQA) tier 3 patient-centered medical homes (PCMH)
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Martha Morehouse GIM ClinicMartha Morehouse GIM Clinic
• >75 Internal Medicine residents; 12 attending physicians
• >20,000 patients
• 1 pharmacist shared faculty; 2 pharmacy residentsresidents
• 5 care coordinators (RN)
• 1 social worker
• 1 medication assistance programs coordinator
• 12 medical assistants
Polypharmacy Service
Polypharmacy Service
Stuart Beatty, PharmD, BCACP, CDEAssociate Professor of Clinical Pharmacy
The Ohio State University College of Pharmacy
Polypharmacy Clinic WorkflowPolypharmacy Clinic Workflow• Medication-focused visit with pharmacist
and internal medicine resident
• Target patients taking ≥ 10 medications
Pre-visit Staff visit
withPatient
receivesscreening
Patient presents
with medications
Assess for drug related
problems
Follow up in one month
with attending
receives education
Polypharmacy Clinic –Preliminary Findings
Polypharmacy Clinic –Preliminary Findings
Med
icat
ion
s
Mean Medications at End of Visit: 19.3 (SD 7.2)
Mean Medications at Start of Visit: 23.7 (SD 6.6)
Nu
mb
er o
f M
Patient
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Polypharmacy Clinic Value
Polypharmacy Clinic Value
• 5-6 patients scheduled per ½ day– 1 attending physician, 1-2
medical residents, 2 pharmacists, medical students,pharmacists, medical students, pharmacy students
– Could be modified to pharmacist only
• Pharmacist billing opportunities for select insurers
• Up-to-date medication list in EMR
Transitional Care Coordination
Transitional Care Coordination
Stuart Beatty, PharmD, BCACP, CDEAssociate Professor of Clinical Pharmacy
The Ohio State University College of Pharmacy
Transitional Care Coordination
Transitional Care Coordination
• 99495/99496 introduced in January 2013• Contact by “licensed clinical staff” within 2
business days of discharge from acute care setting
Type of contact Acute Care SettingType of contact
• Phone
• Face-to-face
• Face to face visit with physician within 7-14 days• Continued coordination 30 days post-discharge
Acute Care Setting• Acute or rehabilitation
hospital• Observation unit• Nursing facility
Transitional Care Coordination Workflow
Transitional Care Coordination Workflow
Patient Discharged• Discharge summary sent to physician
Physician review to determine complexity• Message electronically sent to pharmacistMessage electronically sent to pharmacist
Pharmacist contacts within 2 business days• Assess patient; medication reconciliation;
confirm appointments; document
Patient follow-up within 7 or 14 days• Pharmacist’s note leads to focused visit
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Transitional Care Coordination
Transitional Care Coordination
• Results from 4/1/13 – 7/31/13 (n=68)
• Demographics
– Female 62%– Female 62%
– Mean age – 67.1
– White 66%; African American 31%
– Medicare 60%; Private 22%
Transitional Care Coordination
Transitional Care Coordination
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7
8
9
Top 3 Discharge Diagnosis
0
1
2
3
4
5
6
Diabetes CHF CAP COPD CKD UTI
Transitional Care Coordination
Transitional Care Coordination
• Discharge location:
– OSUWMC – 59%
• Average medications upon discharge –g p g14.7
– 37.3% on opioid
– 34.3% on anticoagulant
– 25.3% on antibiotic
– 25.3% on insulin
Transitional Care Coordination
Transitional Care Coordination
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Transitional Care Coordination
Transitional Care Coordination
Transitional Care Coordination
Transitional Care Coordination
• Medication-related problems
– Identified in 60% of phone calls
Did not start NEW medication 15Did not start NEW medication 15
Taking medication incorrectly (e.g., wrong dose, time) 10
Continued to take a STOPPED medication 5
Experienced adverse effect 5
Warfarin without INR monitoring scheduled 6
CPT code tRVU wRVU tRVU -wRVU
99214 3.13 1.49 1.64
99495 4 82 2 11 2 71
Transitional Care Coordination ValueTransitional Care
Coordination Value
99495 4.82 2.11 2.71
99215 4.20 2.10 2.10
99496 6.79 3.05 3.74
• Efficient hospital follow-up visit
• Reduced rehospitalizations?
Why patients do not fill their
i ti
Why patients do not fill their
i tiprescriptionsprescriptions
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Common drug-drug interactionsCommon drug-
drug interactionsdrug interactionsdrug interactions
Population ManagementPopulation Management
Kelli Barnes, PharmD, BCACPAssociate Professor of Clinical Pharmacy
The Ohio State University College of Pharmacy
Population ManagementPopulation Management
• Uses EMR-reporting capabilities– Patient registries (PCMH
requirement)Proactive targeted interventions• Proactive, targeted interventions
• Incorporates team-based care• Improves outcomes in specific
population• Can be completed outside of an office
visitEMR: Electronic Medical Record
Population Management ProcessPopulation Management Process
Identify population
Generate report
Implement Intervention
Track Outcomes
Update EMR
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Herpes zoster vaccination
OSU GIM PopulationManagement Interventions
OSU GIM PopulationManagement Interventions
Preventative Health
Chronic Kidney Disease Management
Bisphosphonate Use
Chronic Disease State Management
Medication Monitoring
OSU GIM: The Ohio State University Division of General Internal Medicine
Herpes zoster vaccination
OSU GIM PopulationManagement Interventions
OSU GIM PopulationManagement Interventions
Preventative Health
Chronic Kidney Disease Management
Bisphosphonate Use
Chronic Disease State Management
Medication Monitoring
OSU GIM: The Ohio State University Division of General Internal Medicine
Herpes Zoster VaccinationHerpes Zoster Vaccination
Identify population
Generate report
Preventative HealthPreventative Health
p
Implement Intervention
Track Outcomes
Update EMREMR: Electronic Medical Record
HZV: Herpes Zoster Vaccine
Herpes Zoster VaccinationHerpes Zoster VaccinationIdentify population
Generate report
Patients without herpes zoster vaccine
Age ≥ 60 No documented HZV in EMR
Preventative HealthPreventative Health
Implement Intervention
Track Outcomes
Update EMR
Pharmacist review of EMRHZV prescription sent to patient
EMR Updated
EMR: Electronic Medical Record HZV: Herpes Zoster Vaccine
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Herpes Zoster VaccinationHerpes Zoster Vaccination
2,981 patients age ≥ 60 years
identified
2,589 patients age ≥ 60 years with no documented HZV
Preventative HealthPreventative Health
no documented HZV
Standard Caren = 2,089
Interventionn=500
No Personal Health Record
n = 250
Personal Health Recordn = 250
HZV: Herpes Zoster Vaccine
Herpes Zoster VaccinationHerpes Zoster Vaccination
8%
10%
12%
14%p=0.0001
Preventative HealthPreventative Health
0%
2%
4%
6%
8%
Personal Health Record Non‐personal Health Record
Control Intervention
p=0.0007
Herpes zoster vaccination
OSU GIM PopulationManagement Interventions
OSU GIM PopulationManagement Interventions
Preventative Health
Chronic Kidney Disease Management
Bisphosphonate Use
Chronic Disease State Management
Medication Monitoring
OSU GIM: The Ohio State University Division of General Internal Medicine
Chronic Kidney DiseaseChronic Kidney Disease
Identify population
Generate report
Chronic Disease State ManagementChronic Disease State Management
p
Implement Intervention
Track Outcomes
Update EMR
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Chronic Kidney DiseaseChronic Kidney Disease
Identify population
Generate report
Chronic Kidney Disease
eGFR < 60 mL/min/1.73m2
Chronic Disease State ManagementChronic Disease State ManagementChronic Disease State ManagementChronic Disease State Management
p
Implement Intervention
Track Outcomes
Update EMR
KDOQI Guideline Recommendations
Renal Medication Dosing
EMR Updated
CKD Baseline CharacteristicsCKD Baseline CharacteristicsSex N = 146Female 96 (65.8%)
Mean Age in years 71.6 ± 12.2Mean Number of Medications on List 13 ± 5RaceAfrican American 24 (16.4%)
Chronic Disease State ManagementChronic Disease State ManagementChronic Disease State ManagementChronic Disease State Management
White 112 (76.7%)Other 10 (6.8%)
CKD StageStage 3 139 (95.2%)Stage 4 5 (3.4%)Stage 5 2 (1.4%)
ComorbiditiesHypertension 123 (84.3%)Diabetes 54 (37%)
Chronic Kidney DiseaseChronic Kidney Disease3,214 patients identified and
eGFR calculated
328 (10.2%) patients with eGFR < 60 mL/min/1 73m2
Chronic Disease State ManagementChronic Disease State ManagementChronic Disease State ManagementChronic Disease State Management
mL/min/1.73m2
Excludedn = 182
Interventionn=146
CKD Identified as Medical Problem
Before Pharmacist Intervention
Chronic Disease State Management
Identified as medical problem in EMR
Not identified as medical problem in EMR
N = 95 (65%)
N = 51 (35%)
N = 145 (99.3%)
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CKD Medication Safety
Medications N t R i i
Medications RequiringRenal AdjustmentN = 270 (14.1%)
Chronic Disease State Management
Not RequiringRenal
AdjustmentN = 1,645 (85.9%)
CKD Medication SafetyBefore Pharmacist Intervention
Chronic Disease State Management
Medication NOT renally dose adjusted
Medication renally dose adjusted
N = 138(51.1%)
N = 132(48.9%)
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Herpes zoster vaccination
OSU GIM PopulationManagement Interventions
OSU GIM PopulationManagement Interventions
Preventative Health
Chronic Kidney Disease Management
Bisphosphonate Use
Chronic Disease State Management
Medication Monitoring
OSU GIM: The Ohio State University Division of General Internal Medicine
Bisphosphonate UseBisphosphonate Use
Identify population
Generate report
HighHigh--risk Medication Monitoringrisk Medication MonitoringHighHigh--risk Medication Monitoringrisk Medication Monitoring
Implement Intervention
Track Outcomes
Update EMR
EMR: Electronic Medical Record
Bisphosphonate UseBisphosphonate Use
Identify population
Generate report
Bisphosphonate Use
Bisphosphonate listed as medication list in EMR
HighHigh--risk Medication Monitoringrisk Medication MonitoringHighHigh--risk Medication Monitoringrisk Medication Monitoring
Implement Intervention
Track Outcomes
Update EMR
medication list in EMR
Reason for Use, Length of Treatment
eGFR, Calcium use
EMR Updated
EMR: Electronic Medical Record
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Bisphosphonate UseBisphosphonate Use687 patients identified on
bisphosphonate
Excludedn = 325
Eligible for Inclusion
n=362
High Risk Medication MonitoringHigh Risk Medication MonitoringHigh Risk Medication MonitoringHigh Risk Medication Monitoring
n 362
Interventionn=142
Controln=220
30%
35%
40%
45%
50%
Bisphosphonate UseBisphosphonate Use
35.5%
High Risk Medication MonitoringHigh Risk Medication MonitoringHigh Risk Medication MonitoringHigh Risk Medication Monitoring
39.5%
0%
5%
10%
15%
20%
25%
30%
8.5%
Intervention Group Control Group
17.6%
Pre-Intervention Post-Intervention
Reasons for Inappropriate Bisphosphonate Use
High Risk Medication Monitoring
RenalFunction24%24%
Length of Therapy32%
Insufficient Fracture Risk
44%
Population ManagementPopulation
Management• Proactive, targeted interventions
– MANY other opportunities
• Team-based careTeam based care
• Can occur outside of office visit
• Patient-centered medical home credentialing, etc
• Improves patient outcomes